Maximizing renal artery length in right laparoscopic donor nephrectomy by retrocaval exposure of the aortorenal junction

Midline Rotation of the Right Renal Hilum During Hand-Assisted Laparoscopic Living Donor Nephrectomy

BACKGROUND/OBJECTIVES

Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney.

METHODS

Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 - 36. Graft vein and arterial anastomosis data were also reported.

RESULTS

Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 - 60) and 53 (3 - 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications.

CONCLUSIONS

The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery.

Minimally Invasive Surgery for Live Kidney Donors: Techniques and Challenges

Live kidney donation is assuming an increasingly prominent role in kidney transplantation programs. The traditional operative approach has been through an incision in the upper quadrant of the abdomen or in the loin, with the attendant potential postoperative complications associated with a large surgical wound. These problems may act as disincentives to prospective donors. The introduction of laparoscopic donor surgery in 1995 heralded a new era offering reduced postoperative pain and improved cosmetic result. It is hoped that these benefits may counter some disincentives and thereby increase donation rates. Three minimal-access approaches and their advantages and disadvantages are described: classical laparoscopic, hand-assisted laparoscopic, and retroperitoneoscopic surgery. Published reports indicate extensive experience with the first 2 of these approaches and less experience with the latter. All 3 approaches present technical, physiological, and anatomical challenges in the context of retrieving an organ that is fit for transplantation. For minimal-access surgery to be accepted as the procedure of choice for live kidney donors, it must be demonstrated that morbidity is not transferred from donor to recipient when these techniques are used. Some concerns about these procedures are addressed. High-level evidence in the form of randomized controlled trials is generally lacking, but experiences of surgeons and patients suggest that, with appropriate modifications, these techniques are safe for both donors and allografts and also benefit donors' recovery.

When one becomes more: minimum renal artery length in laparoscopic live donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy may convert short main arteries into multiple arteries, increasing the technical challenge of implantation. We evaluated our experience to identify factors predictive of multiple arteries after laparoscopic nephrectomy.

METHODS

All laparoscopic nephrectomies from the start of our program in November 2002 until June 2013 were studied, and preoperative imaging reviewed for donor artery length and multiplicity together with operative findings.

RESULTS

A total of 287 consecutive laparoscopic live donor nephrectomies (64 right and 223 left nephrectomies) were studied. Renal artery length was measured from preoperative donor magnetic resonance or computed tomography angiogram and nephrectomy performed using a laparoscopic stapling device. Nine left kidneys with a single artery (6, 7, 9, 10, 11, 12, 13, 14, and 16 mm in length) and five right kidneys with a single artery (5, 13, 15, 20, and 26 mm) on imaging resulted in multiple renal arteries at implantation. Complex renal vein anatomy was associated with multiple arteries following retrieval.

CONCLUSION

A main renal artery length of more than 16 mm on the left and 26 mm on the right is unlikely to result in multiple arteries to implant. The possibility of multiple arteries should be borne in mind when the donor renal artery is short.

Right-sided transperitoneal hand-assisted laparoscopic donor nephrectomy: is there an issue with the renal vessels?

OBJECTIVE

Short right renal vessels might complicate kidney transplantation, thus causing traction and difficulties during anastomosis. Single-center prospective comparison of right- and left-sided transperitoneal hand-assisted laparoscopic donor nephrectomy (HALDN) is presented.

PATIENTS AND METHODS

Eighty-two living kidney donors underwent HALDN between 2003 and 2008. Right-sided HALDN was performed in 46 living kidney donors. The operative technique of right-sided HALDN was modified to obtain the maximum length of right renal vessels. Outcome data in donors including quality of life as well as graft outcome in recipients were prospectively collected.

RESULTS

All procedures were laparoscopically completed with no conversion. Mean operative time was 127 minutes (vs. 138 minutes in left HALDN, p = 0.08). The mean warm ischemia time was 41 seconds (vs. 39 seconds in left HALDN, p = 0.23). There was no renal artery or vein thrombosis in any of the grafts. Mean blood loss was 81 mL (vs. 92 mL in left HALDN, p = 0.09). Hospital discharge was on an average of 3.6 days postoperative. Delayed graft function occurred in two recipients: one in the left group and the other in the right group. One-year graft survival rate was 95% in the left group versus 96.9% in the right group (p = 0.08). Further, no statistically significant difference in serum levels of creatinine was seen between the groups 1 year after the transplantation.

CONCLUSIONS

Right HALDN is technically safe and feasible and results in convenient extension of right renal vessels to full length with no increased incidence of vascular thrombosis.

Evaluation of cadaveric renal vein lengths and their extension loss with three types of ligature and section

BACKGROUND AND PURPOSE

The right kidney has been less frequently used in live donor nephrectomy, because of the shorter length of the right renal vein (RRV) that is associated with technical difficulties and higher rates of venous thrombosis. In live open donor or deceased donor transplant nephrectomy, an additional cuff of the inferior vena cava is usually removed, but this is a more difficult and risky maneuver in laparoscopic nephrectomy. For this reason, laparoscopic right nephrectomy (LRN) for renal transplantation (RT) is not frequently performed in most medical institutions. We evaluate the difference between RRV and left renal vein (LRV) lengths in cadavers, as harvested for RT by three clamping methods. Our objective was to obtain information that could clarify when LRN for RT should be encouraged or avoided with regard to conventional surgery.

MATERIALS AND METHODS

Ninety adult fresh unfrozen cadavers were randomly divided into three groups of 30, according to the clamping device used: Satinsky, stapler, and Hem-o-lok clip. The abdominal viscera were removed through a median xyphopubic incision, and the veins were measured on the bench. Two lateral limits were used: The renal hilum and the tangential line of the renal poles. As for medial limits, the inferior vena cava or the laparoscopic clipping device on the RRV were used on the right side, while on the LRV, the medial border of the emergence of the adrenal vein was considered. After section of the renal vein, a slight traction of the extremity was applied for the measurement. All measurements were obtained three times using a metallic millimetric ruler, and the arithmetic mean was considered. The chi-square, one-way analysis of variance, and paired t tests were used for statistical analysis. Statistical significance was accepted at P <or= 0.05.

RESULTS

The groups of cadavers were homogeneous in demographic characteristics. Regardless of the clamping method and considering the useful length of the LRV, the RRV was statistically smaller. The evaluation of the vein length did not depend on the lateral limit considered. Independent of the clamping method, on both sides, the lengths after the vein section were larger than before the section, a fact attributed to traction. Use of a stapler and a single Hem-o-lok presented the same waste of vein length on the right side. On average, the RRV was 13.7% shorter than the LRV.

CONCLUSIONS

With the wide acceptance of laparoscopic live donor nephrectomy, the length difference between the veins of both kidneys is an important issue, and the right kidney is therefore used less than the left, compared with conventional surgery. This article represents the first step to quantify the anatomic length of renal veins in different situations. Certainly, more imagenologic or surgical studies should be carried out before decisions can be made for better selection of patients for LRN.

Maximizing the donor pool: use of right kidneys and kidneys with multiple arteries for live donor transplantation

BACKGROUND

Studies have shown donor and recipient outcomes to be equivalent for laparoscopic donor nephrectomy (LDN) and open donor nephrectomy. In the past, LDN has been avoided in the procurement of the right kidney or organs with multiple arteries. This study compares procurement of right and left kidneys as well as procurement of single- and multiple artery organs.

METHODS

A review of all LDNs at a single institution between August 2000 and December 2007 was performed. The data included estimated blood loss (EBL), need for transfusion, operative time, warm ischemia time, length of hospital stay (LOS), and delayed graft function. Arterial supply was assessed using renal arteriogram or computed tomographic (CT) angiography. Outcomes for multiple versus single artery and left versus right LDN were compared. Student's t-test and chi-square test were used for statistical comparison.

RESULTS

A total of 230 LDNs were performed. Multiple arteries were present in 37 donors. The right kidney was procured from 36 donors. No significant difference in EBL, transfusions, operative time, or LOS was noted between multiple and single or right and left LDNs. Warm ischemia time was significantly longer for multiple arteries (mean, 83 s) than for single arteries (mean, 63 s; p = 0.007), and for right kidneys (mean, 86 s) than for left kidneys (mean, 62 s; p = 0.001). No significant difference in delayed graft function was seen in the comparison of multiple (21.6%) and single (11.4%) artery organs (p = 0.11) or of right (13.9%) and left (12.9%) kidneys (p = 0.79).

CONCLUSIONS

The presence of multiple arteries or the need to procure the right kidney does not affect the operative outcome of laparoscopic donor nephrectomy. Warm ischemia time may be greater for these groups, but this does not result in delayed allograft function. The laparoscopic approach should be the standard of care even when expansion of the donor pool includes organs with multiple arteries and procurement of the right kidney.

Laparoscopic Live Donor Right Nephrectomy: A New Technique to Maximize the Length of the Renal Vein Using a Modified Endo GIA Stapler

OBJECTIVES

To report the utilization of a modified Endo GIA vascular stapler to obtain the full length of the renal vein during transperitoneal laparoscopic live donor right nephrectomy.

METHODS

We used a modified Endo GIA stapler, in which the triple staggered rows of staples were removed from the kidney donor side to obtain the full length of the right renal vein. This technique has currently been used in nine consecutive transperitoneal laparoscopic right donor nephrectomies.

RESULTS

With this technique, the entire right renal vein length was harvested in all cases, without vascular complications. Mean renal warm ischemia time from clamping of the renal vessels to cold perfusion was 135s, and mean receptor postoperative glomerular filtration rate after 30 d was 67.3 ml/min. There were no graft losses.

CONCLUSIONS

A novel technique for laparoscopic live donor right nephrectomy is described. It allows harvesting the full length of the right renal vein in a safe and feasible way without compromising warm ischemia time.

Hand-assisted right laparoscopic live donor nephrectomy

PURPOSE

Laparoscopic live donor nephrectomy has acquired an important role in the era of minimally invasive surgery. Laparoscopic harvesting of the right kidney is technically more challenging than that of the left kidney because of the short right renal vein and the need to retract the liver away from the right kidney. The aim of this article is to report our experience with right laparoscopic live donor nephrectomies.

MATERIALS AND METHODS

We performed a retrospective review of 28 patients who underwent right laparoscopic donor nephrectomies at our service. Operative data and postoperative outcomes were collected, including surgical time, estimated blood loss, warm ischemia time, length of hospital stay, conversion to laparotomy and complications.

RESULTS

The procedure was performed successfully in all 28 patients. The mean operative time was 83.8 minutes (range 45 to 180 minutes), with an estimated blood loss of 111.4 mL (range 40 to 350 mL) and warm ischemia time of 3 minutes (range 1.5 to 8 minutes). No donor needed conversion to open surgery and all kidneys showed immediate function after implantation. The average time to initial fluid intake was 12 hours (range 8 to 24 hours). Two cases of postoperative ileus and a case of hematoma on the hand-port site were observed. The mean postoperative hospital stay was 3 days (range 1 to 7 days).

CONCLUSIONS

Our data confirm the safety and feasibility of right laparoscopic donor nephrectomy and we believe that the right kidney should not be avoided for laparoscopic donor nephrectomy when indicated.

Assessment of 100 Live Potential Renal Donors for Laparoscopic Nephrectomy with Multi–Detector Row Helical CT

PURPOSE

To retrospectively review the authors' experience with multi-detector row helical computed tomography (CT) in assessing 100 consecutive live potential renal donors.

MATERIALS AND METHODS

Hospital ethical committee approval was obtained; informed patient consent was not required. One hundred potential renal donors underwent multi-detector row CT assessment. Nonenhanced, arterial phase, and nephrographic phase examinations were performed. Delayed topograms were acquired to visualize the collecting system anatomy. A vascular radiologist prospectively interpreted the multi-detector row CT images. A second vascular radiologist, blinded to the initial results, retrospectively reviewed the images. Eighty candidates subsequently underwent donor nephrectomy, including 70 laparoscopic donor nephrectomies (LDNs) and 10 open donor nephrectomies (ODNs). Surgical findings served as the reference standard for 80 kidneys. The imaging findings in all 100 candidates (200 kidneys) were reviewed, although these findings were considered observational data only because there was no reference standard for 120 kidneys.

RESULTS

Multi-detector row CT findings predicted uncomplicated LDN in 67 of 70 patients. Small upper-pole capsular arteries arising from the distal main renal artery in two patients were not described in the multi-detector row CT report: In one patient, the arising vessels resulted in conversion to ODN because of bleeding; in the other patient, arterial reconstruction was performed. In another patient, conversion to ODN was necessary because of ongoing bleeding from an avulsed large lumbar venous tributary to the left renal vein. Observational data revealed that multiple renal arteries--most of which were accessory renal arteries--were seen in 52 (26%) kidneys. Early branching of the main renal artery was seen in 24 (12%) kidneys, and main renal arterial abnormalities were identified in six (3%). Capsular arteries were detected in 10 (5%) kidneys. Major variations in the anatomy of the main renal veins--including multiple right renal veins, a retroaortic left renal vein, and a circumaortic left renal vein--were seen in 28 (14%) kidneys. Large (>5 mm in diameter) systemic tributaries to the left renal vein were seen in 25 (25%) kidneys. There was no significant interobserver disagreement between the vascular radiologists.

CONCLUSION

Multi-detector row CT findings can predict successful LDN in live potential renal donors.

Laparoscopic right living donor nephrectomy

INTRODUCTION

Left laparoscopic donor nephrectomy (LDN) is preferred over right LDN due to technical ease. The purpose of this study was to compare results between right and left LDN and thereby determine whether substantial experience with right LDN can provide results equivalent to left LDN.

METHODS

All LDN from 2000 to 2004 were reviewed, and right LDN data compared to left LDN data. Statistical analyses included chi-square and Student t tests.

RESULTS

Two hundred thirteen left LDN (84%) were compared to 40 right LDN (16%). Donor age, gender, race, and body mass index, and multiple arteries were similar in right and left LDN groups. Operative and cold ischemia times were similar, but warm ischemia was longer for right LDN (3:55 +/- 1:22 minutes) than left LDN (3.18 +/- 1:06 minutes; P = .004). Despite this, renal allograft function was similar on postoperative day 7 (creatinine 1.77 +/- 1.21 for right LDN, 1.7 +/- 1.5 for left LDN) and at 1 year (right LDN 1.5 +/- 0.4, left LDN 1.23 +/- 0.28). Graft survival rate in the right LDN at 1 year was 97.5%.

CONCLUSIONS

This large experience with right LDN indicates that results comparable to left LDN can be obtained. This observation increases the options for LDN in patients with multiple left renal arteries, or with right renal cysts, or with right kidneys that are smaller in size compared to the contralateral left kidney.

Renal transplantation with iliac vein transposition

We evaluated a technique for implantation of right kidneys with short renal veins without the need for venous reconstruction.

METHOD

The technique of iliac vein transposition was performed in six recipients who received right kidneys with short renal veins. Two cases were living related donors, two were living unrelated, one was an autotransplant, and one was a cadaver kidney recipient. The common and external iliac veins and arteries of the recipient were thoroughly mobilized, allowing for the lateral transposition of the external iliac vein with respect to the external iliac artery. The renal vessels were subsequently implanted in an end to side fashion onto the corresponding transposed external iliac vessels. After implantation, the iliac vein remained lateral with respect to the iliac artery.

CONCLUSIONS

The technique described allows for the implantation of right kidneys without the need for venous reconstruction. Such an approach is especially useful in cases of grafts with short veins.

Controle dos vasos renais usando clips vasculares e fio cirúrgico em nefrectomias vídeo-assistidas de doadores vivos

OBJETIVO: A nefrectomia laparoscópica em doadores vivos para transplante renal vem assumindo um papel importante na era das cirurgias minimamente invasivas, acarretando menor morbidade aos doadores, e resultados semelhantes à técnica aberta no que se refere ao enxerto renal. O objetivo do presente artigo é relatar a experiência do nosso serviço utilizando a técnica de controle dos vasos renais usando fio cirúrgico e clips vasculares. MÉTODO: Foram realizadas 45 nefrectomias utilizando a técnica vídeo-assistida, com ligadura dos vasos renais com clips de titânio (LT-300) e fio cirúrgico. As variáveis analisadas foram tempo cirúrgico, perda sangüínea, tempo de isquemia quente, permanência hospitalar, necessidade de conversão e complicações. RESULTADOS: O procedimento foi realizado com sucesso em todos os casos. O tempo cirúrgico médio foi de 118 minutos, com perda sangüínea estimada em 84ml e tempo de isquemia quente de 4,3 minutos. Dois casos de íleo prolongado, uma lesão de veia gonadal, um escape de artéria renal e uma necrose de ureter foram observados. A permanência hospitalar média foi de 3,7 dias. O uso de clips vasculares e fio cirúrgico reduziu a perda de tecido venoso comparado à técnica com staplers e gerou redução de custos. CONCLUSÕES: A nefrectomia vídeo-assistida com a técnica descrita é factível e mostrou ser efetiva na contenção de gastos e na redução de tecido venoso perdido.

Laparoscopic Right Donor Nephrectomy: A Large Single-Center Experience

BACKGROUND

Laparoscopic procurement of right donor kidneys is frequently avoided or performed using hand-assist devices because of concerns regarding donor safety, adequate exposure, and vessel length. The present study describes the authors' large series of right donor nephrectomies performed laparoscopically without the use of hand ports or other manual assist devices.

METHODS

The authors retrospectively analyzed all right laparoscopic donor nephrectomies performed at their center from November 1, 1999, to February 20, 2004. Study variables included operative times, blood loss, hospital stay, graft function, and donor and recipient complications. Left donor nephrectomies performed during the same period served as controls.

RESULTS

Of 387 laparoscopic kidney procurements, 54 (14 %) were right nephrectomies. Blood loss, extraction times, length of stay, and overall complication rates were similar between right and left donor groups. The mean operative time in the right nephrectomy group was significantly shorter than in the left nephrectomy group (169 +/- 25 and 186 +/- 29 min, respectively; P = 0.003). Graft function 1 month after transplantation and the incidence of delayed graft function were similar in both groups. There was one graft loss caused by thrombosis in the left nephrectomy group; other graft-related complications in the recipients were similar in both groups.

CONCLUSIONS

This large single-center experience demonstrates that laparoscopic right donor nephrectomy performed without hand-assist devices is safe and yields kidneys with excellent function. The authors conclude that selection of the appropriate kidney for donation using this approach can be based on the same criteria that have traditionally governed open donor nephrectomy.

Technique, Indications and Outcomes of Pure Laparoscopic Right Donor Nephrectomy

PURPOSE

Laparoscopic nephrectomy for living renal transplantation has emerged as the gold standard. Nevertheless, experience with this technique for procuring right kidneys is limited. We report our single institution results of pure laparoscopic right donor nephrectomy.

MATERIALS AND METHODS

Laparoscopic donor nephrectomy was initiated at the our institution in November 1999. Patient selection was initially limited to the left kidney but right surgery was started 2 years later after 97 operations had been performed. We prospectively acquired data on the donor and recipient, and specifically analyzed outcomes of the right kidneys.

RESULTS

In a 40-month period 300 laparoscopic donor operations were performed. Overall 44 procedures (15%) were on the right side with the fraction greater (22%) after removing exclusion of the right kidney from laparoscopic selection criteria. In this cohort mean operative time was 170 minutes, significantly less than the 190 minutes for 50 contemporaneous left kidneys (p = 0.001). No case of right donor nephrectomy required open conversion and vessels were of adequate length. Donor and recipient complications were similar in the 2 groups without technical graft loss in the entire series.

CONCLUSIONS

Our method of laparoscopic right donor nephrectomy yields excellent graft quality with adequate vascular length and without the need for elaborate modifications or hand assistance. Moreover, the right operation is technically easier and it achieved comparable donor morbidity and recipient renal function. With sufficient experience the right kidney should be procured laparoscopically when indicated.

Right laparoscopic live donor nephrectomy: a single institution experience

BACKGROUND

Laparoscopic live donor nephrectomy (LLDN) is increasingly used by transplantation centers worldwide. As in open live donor nephrectomy, the left kidney is preferred for LLDN; however, not all potential donors have anatomy conducive to left nephrectomy. The purpose of our study, therefore, was to report on a large, single-institution experience with right LLDN performed using a hand-assisted, transperitoneal approach.

METHODS

We performed a retrospective review of 40 consecutive patients who underwent transperitoneal right hand-assisted LLDN at our institution. Information on donor age, relation to recipient, and indication for right-sided donation was collected. Surgical demographics included operative time, warm ischemia time, and estimated blood loss. Recipients were followed for graft loss and for long-term renal allograft function.

RESULTS

The indications for right-sided donor nephrectomy were a difference in split renal function of greater than 10%, multiple left renal vessels, and right renal cysts. The mean surgical time in our series was 115.8 min, with a mean estimated blood loss of 85.7 mL and a warm ischemia time of 116.0 seconds. Surgical and postoperative complications were limited. Mean serum creatinine levels in the recipients were 1.6 mg/dL on day 7, 1.4 mg/dL on day 30, and 1.4 mg/dL at 1 year after transplantation.

CONCLUSIONS

Right LLDN using a hand-assisted, transperitoneal technique was performed with minimal morbidity and favorable graft function. We believe that offering hand-assisted LLDN to patients with an indication for right-sided donation can safely and effectively increase the pool of donor organs available to patients with end-stage renal disease.